This briefing looks at what the vanguards set out to achieve when it comes to involving and engaging staff in the new care models. It highlights the work some of the vanguards have been doing and shares the lessons that other organisations and partnerships can take from the vanguards’ experiences.
What were the vanguards’ ambitions?
Transformational change is not easy, and the engagement of all parts of the system involved in developing and delivering new models of care within the vanguards has been fundamental to their success. This includes putting the workforce at the heart of the change. The Five year forward view (the Forward view) praised the dedication of health and care staff for their role in the remarkable efficiency achievements in the last few years. However it also recognised that to achieve sustainable improvements in the long term, fundamental changes are needed to the way health and care services are delivered, which involves staff working in different ways.
Historically, the NHS and local government has approached the workforce from the perspective of single organisations, rather than viewing the future health and care needs of local people and what skills will be needed to support them across the system. The focus has tended to be on short-term requirements – such as focusing on getting the right number of training places for the near-term rather than the skills and workforce models to meet future needs. The enormous challenge in tackling the long-term workforce needs has also meant it has been put in the 'too difficult' box and left for another year to solve.
The Forward view suggested: "We can design innovative new care models, but they simply won’t become a reality unless we have a workforce with the right numbers, skills, values and behaviours to deliver it." As part of the new care models programme, NHS England has been supporting areas such as the Encompass vanguard in Kent to model population health data to project the workforce needed over the next 5-15 years. NHS England has also been working with Nottingham vanguards to consider the ongoing analytics capability and capacity required to carry out workforce modelling and management. The vanguards have discovered that considerable attention needs to be given to up-skilling staff and supporting them to adapt how they are working. They also learned it makes sense to work on system-wide strategic workforce planning at the outset of any planning process. However, taking the step from analysing the problem to actually reshaping the workforce for a local system is huge, and has required vanguards to challenge existing cultures, established systems and organisational silos.
To deliver this vision for new care models the vanguards have had to think about how staff can work in different ways to improve services for patients and citizens. This has meant investing in staff training and development, focusing on retention, and in some cases, investing in new roles. Many vanguards have specifically supported staff to work across organisational and sector boundaries, developing new models of staffing and redesigning infrastructure, such as information sharing systems, to enable this. They have also placed a strong emphasis on empowering staff to lead services changes, engage staff in the transformation programmes, and considered how staff themselves can be supported to look after their own health and wellbeing.
The vanguards have discovered that considerable attention needs to be given to up-skilling staff and supporting them to adapt how they are working. They also learned it makes sense to work on system-wide strategic workforce planning at the outset of any planning process.
What can we learn from the vanguards?
Breaking down barriers across whole systems
- Enabling different groups of staff across health, social care, the voluntary sector and wider public sector to work together, as well as 'breaking down the barriers' between organisations and different staff groups can help people to break out of old working patterns and think differently. Bringing staff and patients together to consider how services can be truly designed around the needs of the people using them, can be a very powerful way to engage staff in the need for change and build a common purpose.
- Effective leadership is a critical enabler for change. Leaders can set an example by investing in relationships at the highest level, with partners across the local health and care system, and inspire staff at the front line to do the same.
- The vanguard experience shows that change takes time. It can take months for teams to start to feel able to communicate honestly and challenge each other openly. People need time and support to adjust to new ways of working, including overcoming the initial equipment and data sharing ‘teething problems’ that often arise.
- In the move to new models of care that span traditional organisational boundaries, services can no longer focus purely on workforce planning in silos. Some vanguards, like All together better Sunderland feel they benefitted from commissioning an independent organisation to carry out an insightful and honest view of workforce development and planning challenges across a whole area.
- Working across whole systems also has the potential to help tackle challenges many organisations face in recruiting and retaining staff. The acute care collaboration vanguards are demonstrating new, flexible approaches, to their workforce strategies.
- Developing relationships and partnerships with the voluntary sector can be particularly valuable for understanding the needs of local populations and delivering person-centred services that transcend traditional service divides. The Isle of Wight vanguard has worked with Age UK to develop the role of care navigators who support people to get the right support to manage a wide range of health and care needs.
Engaging staff and communicating change
- Many vanguards have recognised that staff on the frontline often have the best ideas about how to improve it – but they need to feel empowered to do so.
- Involving as wide a range of staff as possible, as early as possible, in service change programmes is critical. Staff need to have a safe space where they can express their views and fears, and know that mechanisms are in place to address issues raised and feedback.
- The vanguards have adopted a range of methods to gather the input of staff, including surveys, hosting engagement events, drop-in sessions and commissioning research partners to gauge the impact of the change on staff over the long term. While there is no 'right' way to do staff engagement, providing a range of different opportunities for staff to get involved is the best way to ensure as many people as possible who want to contribute can do so.
- Staff need to be empowered to lead the change. At Better care together Morecambe Bay vanguard all five of the work streams are led by health and care professionals working in partnership with managers.
- The vanguards have also taken specific steps to engage clinicians. At the Better together Mid Nottinghamshire vanguard the project team recruited a senior clinical champion who could advocate the use of the new technology among their peers. Engaging GPs has been a particular focus for many of the vanguard projects, who have worked with local GPs to effectively integrate general practice with new models of care.
- Many of the vanguard projects have benefitted from 'going where the energy is', that is, working with those groups of staff who are keen to embrace and lead change. Within the Foundation Group partnership between Dartford and Gravesham NHS Trust and Guy’s and St Thomas’ NHS Foundation Trust three clinical faculties were chosen for projects because they actively wanted to use the opportunity to work on particular improvement issues. Building on this energy gives the project the best chance of success and generates enthusiasm among other clinical teams to follow.
- It is not feasible for everyone working in the health and social care sector to participate directly in designing new models of care. So it is equally important to communicate change effectively, including the benefits it will bring. This means having a clear vision and a consistent message.
It is not feasible for everyone working in the health and social care sector to participate directly in designing new models of care. So it is equally important to communicate change effectively, including the benefits it will bring. This means having a clear vision and a consistent message.
Upskilling and supporting staff to work differently
- Many of the vanguard programmes have had wide ranging implications for staff which can be challenging. They have recognised that investing in training and education to help staff develop new skills is crucial to successfully implementing new models of care.
- This includes focusing on the skills of the most senior leaders, who are being challenged to move from traditional organisation-focused ways of working to leading across systems. Many vanguards have considered how their organisational development strategies can support senior leaders spanning different organisations to work together.
- As organisations look to support staff to work across organisational and sector boundaries, they are increasingly moving to competency based recruitment and training. For example, the Enhanced health in care homes framework suggests that care practitioners should be trained in competencies such as wound management, nutrition and falls, and all staff should be offered training in other complex conditions or pathways, such as dementia and end-of-life care.
Inspiring staff through effective leadership
- Leaders should challenge themselves to share leadership and responsibility, as well as to prioritise talking, and listening, to staff. In Wakefield, the approach has been to trust and empower staff to make their own decisions based on what’s best for people who use services. They also opened up direct lines of communication between frontline staff and chief executives and senior leaders as they adapted to new ways of working.
- The vanguards have benefited from an open leadership culture that encourages change and innovation and supports colleagues to trial new ways of working. Throughout the new care models programme, the ability to fail and learn lessons from failure has been expected and embraced; something that the NHS has traditional struggled to do.
Vanguards in action
Developing new roles to break down boundaries
Care navigators employed as part of the Isle of Wight vanguard help patients to access a complex array of health, social care and voluntary sector services. Providing up to six visits, the care navigator works with the patient to agree a set of goals that matter to them and provide a range of support to help achieve those goals, such as providing information about available services, help with managing money and guidance about self-care. The care navigators input this information onto a database shared with GPs. Working proactively with GPs from the start has been crucial to building trust between the care navigators and GPs, and these relationships have helped GPs to feel confident in making referrals to the care navigators.
Collaborating to overcome recruitment challenges and create positive patient and family experiences
The Foundation Group is a partnership between Dartford and Gravesham NHS Trust (DGT) in Kent and Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in London, and one of the acute care collaboration vanguard sites. Within the paediatrics clinical faculty, neurology was identified as a key area for improvement, in particular, the need to examine whether some elements of care that might currently be undertaken at the Evelina London Children’s Hospital (part of GSTT) could instead be carried out at Darent Valley Hospital (DGT). A main concern was the lack of support for families in the local community following care provided in London.
To provide a comprehensive neurology service an epilepsy specialist nurse needed to be recruited. However, DGT has found it difficult to recruit and retain and clinicians. The trust contacted Roald Dahl’s Marvellous Children’s Charity who agreed to fund the epilepsy specialist nurse post for two years, with a guarantee from the trust of funding for three further years. Thanks to the links between the two trusts, the position attracted a number of high calibre candidates and the specialist nurse began in July 2017. Already, parents have reported feeling pleased that they can access services closer to home, and in the event of having to travel into London, knowing that more support will be available when they return home.
The vanguards have benefited from an open leadership culture that encourages change and innovation and supports colleagues to trial new ways of working. Throughout the new care models programme, the ability to fail and learn lessons from failure has been expected and embraced; something that the NHS has traditional struggled to do.
Leadership and modelling new behaviours
The 27 care homes and six supported living facilities involved in Wakefield Enhanced health in care homes vanguard have been linked to a dedicated GP practice working with multidisciplinary teams including community nurses, therapists, voluntary carers and other professionals. Modelling new behaviours at the top of organisations has been important to the vanguard. A provider alliance was formed by bringing together chief executives and leaders of all the organisations in the district that play a part in health and wellbeing including NHS bodies, local authorities, fire and rescue, housing and the community and voluntary sector. Each chief executive has taken on a system leadership role – many in areas that they may not consider themselves to be experts in. By stepping outside of their comfort zone they are modelling this behaviour for frontline staff who are also being asked to work in different ways.
Multidisciplinary teams providing holistic support
All together better Sunderland (MCP) vanguard have established five multidisciplinary community integrated teams focussing on supporting vulnerable patients with complex conditions who are frequently admitted to hospital. Based at five locations across Sunderland, the teams include GPs, nurses, social care experts and living well link workers. The teams create tailored care plans that reflect patients’ medical, social and emotional needs, with the aim of improving their quality of life and avoiding unnecessary hospital admissions.
The University of Sunderland was commissioned by the vanguard to undertake an action research project to support workforce development. The research recommendations included:
- carrying out a baseline workforce self-assessment
- developing local system workforce data
- carrying out a generic training needs analysis for everyone working in integrated teams
- developing an OD strategy, including plans for both individual and team leadership
- ensuring co-production skills and holistic care skills (including emotional and psychological wellbeing) are built into workforce profiling
- developing a local definition of care coordination as the term had different meanings to different organisations and professionals.
The vanguard faced initial basic operational issues such as agreeing responsibility for equipment, supplies and repairs. At first, some staff struggled to attend multidisciplinary team meetings as they felt they didn’t have time. However, once staff saw how the meetings resulted in faster and more effective ways of managing patients care these problems started to be resolved. Staff have reported improved communication with co-workers and the benefits of being able to address issues over their desks within minutes rather than days. They also feel there has been a positive impact on their own learning and development as a result of working in an integrated team.